Management of a failed esophageal atresia repair in an infant asylee: a case report

Anastomotic leaks are not uncommon after the surgical repair of esophageal atresia (EA) and can cause significant morbidity. Inadequate medical infrastructure and supplies in Central American countries can be associated with poor outcomes. Access to care in resource-rich countries may be considered for patients from low-income countries who have surgical complications and have exhausted all local resources. A female newborn born in Mexico with type-C esophageal atresia underwent primary esophago-esophagostomy two days after birth, near the Mexican Guatemalan border. One week later, an anastomotic leak was noticed, and the local surgeons proceeded with a repeat thoracotomy and re-do anastomosis. The patient was maintained without nutrition because parenteral nutrition was not available. Three weeks later, a recurrent leak was noticed after feedings were introduced. The local surgeons proceeded with a thoracotomy, distal esophageal closure, gastrostomy tube placement, and spit fistula. Having exhausted all local resources, the local surgeon advised the family to seek medical asylum in the U.S. She arrived at the U.S. at the age of 8 months and was first seen at another hospital due to dislodgement of the gastrostomy tube, which was replaced for a button. She was subsequently referred to our hospital. We did a thorough evaluation by rigid bronchoscopy and contrast studies and confirmed the feasibility of an esophageal anastomosis. We communicated extensively through a video platform with the local surgeon from Mexico to discuss the details of all prior procedures in preparation for the anastomosis. We proceeded with a fourth thoracotomy, spit fistula take-down and esophageal anastomosis. She developed a small leak that resolved spontaneously by postoperative day 22. She was supported by jejunal feedings through a GJ tube since postoperative day 1. She was discharged on postoperative day 28 on oral feedings plus GJ supplemental feedings. Direct communication between surgeons across international borders can help in the surgical planning of patients who develop complications and come to the U.S. needing further care.